Aims. Our retrospective analysis reports the outcome of patients operated for slipped capital femoral epiphysis using the modified Dunn procedure. Results, complications, and the need for revision surgery are compared with the recent literature. Methods. We retrospectively evaluated 17 patients (18 hips) who underwent the modified Dunn procedure for the treatment of slipped capital femoral epiphysis. Outcome measurement included standardized scores. Clinical assessment included ambulation, leg length discrepancy, and hip mobility. Radiographically, the quality of epiphyseal reduction was evaluated using the Southwick and Alpha-angles. Avascular necrosis, heterotopic ossifications, and osteoarthritis were documented at follow-up. Results. At a mean follow-up of more than nine years, the mean modified Harris Hip score was 88.7 points, the Hip Disability and Osteoarthritis Outcome Score (HOOS) 87.4 , the Merle d’Aubigné Score 16.5 points, and the UCLA Activity Score 8.4. One patient developed a partial avascular necrosis of the femoral head, and one patient already had an avascular necrosis at the time of delayed diagnosis. Two hips developed osteoarthritic signs at 14 and 16 years after the index operation. Six patients needed a total of nine revision surgeries. One operation was needed for postoperative hip subluxation, one for secondary displacement and implant failure, two for late femoroacetabular impingement, one for femoroacetabular impingement of the opposite hip, and four for implant removal. Conclusion. Our series shows good results and is comparable to previous published studies. The modified Dunn procedure allows the anatomic repositioning of the slipped epiphysis. Long-term results with subjective and objective hip function are superior, avascular necrosis and development of osteoarthritis inferior to other reported treatment modalities. Nevertheless, the procedure is technically demanding and revision surgery for secondary femoroacetabular impingement and implant removal are frequent. Cite this article: 2020;1-4:80–87

Objectives. The purpose of this study was to evaluate the existing literature from 2005 to 2016 reporting on the efficacy of surgical management of patients with femoroacetabular impingement (FAI) secondary to slipped capital femoral epiphysis (SCFE). Methods. The electronic databases MEDLINE, EMBASE, and PubMed were searched and screened in duplicate. Data such as patient demographics, surgical technique, surgical outcomes and complications were retrieved from eligible studies. Results. Fifteen eligible level IV studies were included in this review comprising 261 patients (266 hips). Treatment groups included arthroscopic osteochondroplasty, surgical hip dislocation, and traditional open osteotomy. The mean alpha angle corrections were 32.14° (standard deviation (. sd). 7.02°), 41.45° (. sd. 10.5°) and 6.0° (. sd. 5.21°), for arthroscopy, surgical hip dislocation, and open osteotomy groups, respectively (p < 0.05). Each group demonstrated satisfactory clinical outcomes across their respective scoring systems. Major complication rates were 1.6%, 10.7%, and 6.7%, for arthroscopy, surgical dislocation and osteotomy treatments, respectively. Conclusion. In the context of SCFE-related FAI, surgical hip dislocation demonstrated improved correction of the alpha angle, albeit at higher complication and revision rates than both arthroscopic and open osteotomy treatments. Further investigation, including high-quality trials with standardised radiological and clinical outcome measures for young patients, is warranted to clarify treatment approaches and safety. Cite this article: K. O. Oduwole, D. de Sa, J. Kay, F. Findakli, A. Duong, N. Simunovic, Y. Yi-Meng, O. R. Ayeni. Surgical treatment of femoroacetabular impingement following slipped capital femoral epiphysis: A systematic review. Bone Joint Res 2017;6:472–480. DOI: 10.1302/2046-3758.68.BJR-2017-0018.R1

Aims. The aim of this study was to inform the epidemiology and treatment of slipped capital femoral epiphysis (SCFE). Methods. This was an anonymized comprehensive cohort study, with a nested consented cohort, following the the Idea, Development, Exploration, Assessment, Long-term study (IDEAL) framework. A total of 143 of 144 hospitals treating SCFE in Great Britain participated over an 18-month period. Patients were cross-checked against national administrative data and potential missing patients were identified. Clinician-reported outcomes were collected until two years. Patient-reported outcome measures (PROMs) were collected for a subset of participants. Results. A total of 486 children (513 hips) were newly affected, with a median of two patients (interquartile range 0 to 4) per hospital. The annual incidence was 3.34 (95% confidence interval (CI) 3.01 to 3.67) per 100,000 six- to 18-year-olds. Time to diagnosis in stable disease was increased in severe deformity. There was considerable variation in surgical strategy among those unable to walk at diagnosis (66 urgent surgery vs 43 surgery after interval delay), those with severe radiological deformity (34 fixation with deformity correction vs 36 without correction) and those with unaffected opposite hips (120 prophylactic fixation vs 286 no fixation). Independent risk factors for avascular necrosis (AVN) were the inability of the child to walk at presentation to hospital (adjusted odds ratio (aOR) 4.4 (95% CI 1.7 to 11.4)) and surgical technique of open reduction and internal fixation (aOR 7.5 (95% CI 2.4 to 23.2)). Overall, 33 unaffected untreated opposite hips (11.5%) were treated for SCFE by two-year follow-up. Age was the only independent risk factor for contralateral SCFE, with age under 12.5 years the optimal cut-off to define ‘at risk’. Of hips treated with prophylactic fixation, none had SCFE, though complications included femoral fracture, AVN, and revision surgery. PROMs demonstrated the marked impact on quality of life on the child because of SCFE. Conclusion. The experience of individual hospitals is limited and mechanisms to consolidate learning may enhance care. Diagnostic delays were common and radiological severity worsened with increasing time to diagnosis. There was unexplained variation in treatment, some of which exposes children to significant risks that should be evaluated through randomized controlled trials. Cite this article: Bone Joint J 2022;104-B(4):519–528

Aims

Slipped capital femoral epiphysis (SCFE) is one of the most common hip diseases of adolescence that can cause marked disability, yet there is little robust evidence to guide treatment. Fundamental aspects of the disease, such as frequency, are unknown and consequently the desire of clinicians to undertake robust intervention studies is somewhat prohibited by a lack of fundamental knowledge.

In 2017, the British Society for Children’s Orthopaedic Surgery engaged the profession and all relevant stakeholders in two formal research prioritization processes. In this editorial, we describe the impact of this prioritization on funding, and how research in children’s orthopaedics, which was until very recently a largely unfunded and under-investigated area, is now flourishing. Establishing research priorities was a crucial step in this process.

Cite this article: Bone Joint J 2024;106-B(5):422–424.

Stickler’s syndrome, also called Hereditary Progressive Arthro-Ophthalmopathy, is an autosomal dominant connective tissue disorder with strong expressivity, characterised by ocular, orofacial, skeletal, cardiac, and auditory features. We describe a case of valgus slipped capital femoral epiphysis in a 13 year-old boy with Stickler’s syndrome. He presented at routine rheumatology clinic follow-up with a 1-month history of progressively worsening right hip pain, which radiated to the knee. He underwent insitu cannulated screw fixation of the right slipped capital femoral epiphysis. Joint pains are a common manifestation in Stickler’s syndrome and this might delay the diagnosis of slipped capital femoral epiphysis. Valgus slipped capital femoral epiphysis is a rare entity. Obesity and the increased femoral anteversion are predisposing factors. Insitu fixation with a single cannulated screw is the treatment of choice

Purpose: To evaluate the vascularisation of the femoral head in children with slipped capital femoral epiphysis (SCFE) before and after surgery with use of contrast-enhanced MRI. Methods and Materials: 20 consecutive children, 13 boys and 7 girls, aged 9–15 years, with slipped capital femoral epiphysis, were included into the study. The classification of SCFE was performed traditionally due to the patient’s history, physical examination and findings of the radiographs. There were no pre-slips, 9 children had acute, 5 children had acute-on-chronic and 6 children had chronic SCFE. The MRI-examinations were performed in a 1.5 Tesla MR-scanner with use of the body coil and all postoperative MR-examinations were carried out within 4 weeks after surgery. The examination protocol included a coronal fat-suppressed STIR-sequence, a coronal contrast-enhanced T1-weighted spin-echo sequence and a sagittal 3D-gradient-echo (FFE) sequence. Morphology, signal intensities and contrast-enhancement of the femoral head were assessed retrospectively by two experienced radiologists in consensus. Results: Morphologic distortion of the physis, bone marrow edema in the metaphysis and epiphysis and joint effusion were the preoperative MRI-findings of slipped capital femoral epiphysis in each child. In 17 children, who underwent in situ-fixation with a single screw, and in one child, who underwent open reduction of the epiphysis, the vascularisation of the femoral head before and after surgery was normal. An avascular zone in the posterior-lateral aspect of the epiphysis was visible preoperatively in one child, which completely revascularized after open reduction and internal fixation of the epiphysis with two screws. One child with severe SCFE developed avascular necrosis of the femoral head after open reduction and corrective osteotomy through the physis. Conclusion: MRI allows for accurate evaluation of the femoral head vascularisation before and after surgery in children with slipped capital femoral epiphysis

Introduction: To determine whether there is a correlation between severity of the slip and duration of symptoms in patients presenting with slipped capital femoral epiphysis. Methods: 50 patients with slipped capital femoral epiphysis were identified from the Royal Hospital for Sick Children database from 1998 to 2003. Of these, 47 patients had casenotes and radiographs available. 12 patients had bilateral slips resulting in a total of 59 slipped capital femoral epiphyses studied. On the basis of their history, 16 of these hips were unstable and were excluded leaving 43 stable slips in 35 patients. Case-notes were reviewed and the exact age, weight, symptom duration and treatment were recorded. X-rays were assessed and the slip angle was measured by the technique described by Southwick. Results: The mean age of the patients was 11years 9months (7yrs 5 mths – 16 yrs 5mths). There were 19 males and 16 females. Weights were plotted against age on a centile chart with 85% of patients weighing > 75th centile for age.The mean duration of symptoms was 12.1weeks (2days – 52weeks)The mean slip angle was 22° (5° – 65°)There were 34 mild slips (< 30°), 8 moderate slips (30° – 60°) and 1 severe slip (> 65°). There was no statistical difference in duration of symptoms between these groups. Statistical analysis by ordinal regression analysis showed there was no correlation between slip severity and duration of symptoms. In addition, there was no correlation between slip severity and age or weight. Conclusion: There appears to be no relationship between slip severity and duration of symptoms in patients presenting with stable slipped capital femoral epiphysis

Our objective is to show the results of the unstable slipped capital femoral epiphysis treatment with reduction and threaded screw fixation. A retrospective analysis of 21 patients (13 boys and 8 girls) with unstable slipped capital femoral epiphysis was performed between 1993 and 1998. The right hip was involved in 13 patients and the left hip in 8. The patients presented acute pain and functional difficulties. The diagnoses were based on the clinical presentation, neutral and Lowestein hip x-rays. The treatment consisted on gentle manipulative reduction of the unstable slip (flexion and internal rotation), threaded cannulated screw fixation on orthopaedic table and image intensifier control. Results showed 2 avascular necrosis, 2 bone shortening, 3 limited range of motion. The rest showed satisfactory clinical results in the short term

Aim:. Audit of the outcome of subcapital osteotomy for a series of cases of severe unstable slipped capital femoral epiphysis. Method:. 57 cases of unstable severe slipped capital femoral epiphysis were operated on by a single surgeon between 2000 and 2011. The procedure was performed through the anterior abductor sparing approach. Patients have been followed up prospectively and the results are presented at average follow up is 6.4 years with a minimum of 18 month follow to include all risks of avn. Results:. There were 35 males (average age 13.85 years) and 22 females (average age 12.4 years). Three syndromic cases, 2 Trisomy 21 (with no avn) and one pituitary/corpus callosum agenesis (developed avn) were included. 5 patients (8.7%) developed avn, one syndromic, another with noted avn on pre-operative MRI and the third with partially healed growth plate. Excluding these patients the avn rate was 2/54 (3.7%). Re-operations were performed on the avn group including two head neck debridements and valgus osteotomy, one head neck debridement alone and one arthrodesis. One patient is awaiting debridement and valgus osteotomy. One patient developed chondrolysis and has had no intervention 6 years. 2 patients developed asymptomatic heterotopic bone ossification and the incidence of lateral cutaneous nerve symptoms was 35% none requiring intervention. Leg length difference was less than 1 cm in those patients who did not develop avn. Conclusion:. This single surgeon audit shows lower risk of avn than and strengthens the argument for referral to specific centres for such conditions. Level of evidence: IV

Aim. To inform a working group of UK paediatric surgeons (the UK SCFE Study Group) convened to design pertinent trials in slipped capital femoral epiphysis (SCFE), three centres (Bristol, Newcastle and Barts and The London) reviewed the demographics and management of children with SCFE presenting between 2007 and 2012. Method. At all contributing centres with digital PACS records for a minimum of 5 years, a search for the following terms was made of PACS reports: slipped capital femoral epiphysis, slipped upper femoral epiphysis, SCFE and SUFE. From the results, radiographs and electronically stored clinic letters were assessed to confirm the diagnosis and ascertain age at presentation, incidence of bilaterality, chronicity, stability (Loder criteria), management and complications. Results. A total of 134 SCFEs presented between 2007 and 2012 to the three units. The mean age at presentation was 12.8 yrs (range 6–16 yrs). There were 91 males and 43 females. The left hip was nearly twice as commonly involved compared to the right, with bilateral presentation in 26.5% of patients. The most common mode of presentation was acute-on-chronic. Stable slips were over twice as common as unstable. The most common intervention was percutaneous pinning in situ. Open reduction, osteotomy and stabilisation were required in 21% of cases. The most common complications were osteonecrosis (n=17), screw migration/penetration (n=9), leg length discrepancy (n=9) and symptomatic secondary cam with femoroacetabular impingement (n=7). Conclusion. This three-centre UK study gives insight into the demographics and contemporary management of SCFE, acts as a guide to larger audits of current practice throughout the UK and informs the subject and content of potential future randomised clinical trials

The August 2012 Children’s orthopaedics Roundup. 360. looks at: whether 3D-CT gives a better idea of coverage than plain radiographs; forearm fractures after trampolining accidents; forearm fractures and the Rush pin; the fractured distal radius; elastic stable intramedullary nailing for long-bone fractures; aponeurotic recession for the equinus foot; the torn medial patellofemoral ligament and the adductor tubercle; slipped capital femoral epiphysis; paediatric wrist arthroscopy; and Pirani scores and clubfoot

We treated patients with severe slipped capital femoral epiphysisor SCFE with a posterior tilt angle or PTA of greater than or equal to 60 degrees with a Sugioka transtrochanteric rotational osteotomy. We report on the clinical and radiologic results of tis method. The study was performed on 8 cases (including 9 hips) of slipped capital femoral epiphysis, for which transtrochanteric rotational osteotomy of femoral head (Sugioka method) was carried out in author’s department from 1987 to 1996. The age of onset ranged from 9 to 14 years old (average: 11.6 years). There were 4 boys (4 hips) and 4 girls (5 hips). The follow-up period ranged from 2 years to 10 years (average: 4.4 years). Three of the treated hips were classified as chronic and 6 as acute on chronic. Preoperative head-neck angle (HNA) was 64 – 83 degrees (average: 68 degrees). All patients were performed a transtrochanteric rotational osteotomy of the femoral head which is known as the Sugioka method. The rotational angle was from 70 degrees to 90 degrees. The presence of pain, postoperative range of motion, PTA on postoperative X-rays, avascular necrosis and osteoarthritic change were examined as part of the evaluation of the clinical results. Necrosis of femoral head was found in one case, while no pain was noted in the other cases, and the range of motion was generally satisfactory. In the radiologic results, PTA was improved to 10 – 25 degrees (average: 18.5 degrees). Necrosis of femoral head was observed in one hip, but the results were satisfactory in 7 cases (8 hips). These results suggest that this technique is useful for the treatment of severe cases of slipped capital femoral epiphysis

Introduction and Aims: Practice standards vary considerably for prophylactic pinning the contralateral hip opposite a scfe. This work provides a data-driven framework with which to analyse the risks, benefits, and costs of two modes of treatment: prophylactic pinning the normal side contralateral to a scfe versus observation; and pinning of subsequent slips. Method: A decision analysis model was constructed using the English language literature to estimate SCFE incidence and severity. The model framework assumes that if a hip is pinned prophylactically it will not slip. The benefits of prophylactic pinning are therefore determined by identifying the percentage of contralateral hips that will subsequently slip and then develop early osteoarthritis requiring total hip arthroplasty at a young age. In our cost analysis model, the cost of diagnosis, treatment, and follow-up was developed for the two treatment modes using actual hospital costs and standardised medicare reimbursement schedules for professional fees. Results: If a hip is not pinned prophylactically, there is a 7% risk of requiring a total hip arthroplasty in the contralateral hip at an early age due to osteoarthritis. This 7% is a combination of patients whose contralateral femoral epiphysis slipped moderately or severely and was pinned in a non-anatomic position (1.5% of the initial population) and patients whose substantial slip was not detected (5.5%). The risk of prophylactic pinning appears to be associated with a 0.3% chance of developing avascular necrosis. Other risks would include chances of infection or chondrolysis, although these have not been reported to date. If every patient is managed by the prophylactic pinning protocol, the total cost per patient, not including lost time at work or school, for pinning a slipped capital femoral epiphysis, prophylactically pinning the contra lateral side, and post-operative follow-up is $6266. Conversely, the total cost per patient for the second mode, pinning a slipped capital femoral epiphysis, post-operative follow-up and pinning of subsequent contralateral slips that are detected is $6864. Costs of later hip arthroplasty were not included. This analysis suggests that costs to a national health care system for treatment of SCFE would not increase by prophylactic contralateral pinning. Conclusions: Prophylactic pinning of the contralateral side is merited on the basis of both risk/benefit and cost-effectiveness analyses. Ultimately, the decision must incorporate the physician’s assessment of patient risk factors including: age, weight, co-morbidities, sports activities, the likelihood and feasibility of regular follow-up, and the patient’s and parents’ acceptance of prophylactic surgery

Femoroacetabular impingement (FAI) causes pain and chondrolabral damage via mechanical overload during movement of the hip. It is caused by many different types of pathoanatomy, including the cam ‘bump’, decreased head–neck offset, acetabular retroversion, global acetabular overcoverage, prominent anterior–inferior iliac spine, slipped capital femoral epiphysis, and the sequelae of childhood Perthes’ disease. Both evolutionary and developmental factors may cause FAI. Prevalence studies show that anatomic variations that cause FAI are common in the asymptomatic population. Young athletes may be predisposed to FAI because of the stress on the physis during development. Other factors, including the soft tissues, may also influence symptoms and chondrolabral damage. FAI and the resultant chondrolabral pathology are often treated arthroscopically. Although the results are favourable, morphologies can be complex, patient expectations are high and the surgery is challenging. The long-term outcomes of hip arthroscopy are still forthcoming and it is unknown if treatment of FAI will prevent arthrosis

Introduction and Objective. Several studies have described double and triple femoral neck lengthening osteotomies to correct coxa brevis deformity, however, no overview exists in literature. Our aim was to perform the first systematic review of the outcomes of double and triple femoral neck lengthening. Materials and Methods. After an extensive search in Pubmed, CINAHL and Embase libraries for published articles using the following search strategy: ‘(((proximal femoral deformity) OR hip dysplasia) OR coxa brevis) AND (((femoral neck lengthening) OR double proximal femoral osteotomy) OR triple proximal femoral osteotomy)’, we included studies reporting the results of double and triple femoral neck osteotomies. Clinical and radiological outcomes, and reported complications were extracted. The review process was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Results. After evaluating 456 articles, we included 11 articles reporting 149 osteotomies in 143 patients (31% male, 64% female, 5% unspecified). Mean age of the patients was 20 years (range 7 years to 52 years). Indications were developmental hip dysplasia (51%), Perthes disease (27%), infection (6%), post-trauma (4%), congenital disorders (2%), slipped capital femoral epiphysis (1%), idiopathic (3%) and unknown (6%). The mean limb length discrepancy reduced by 12 mm (0 mm to 40 mm). In total, 65% of 101 positive Trendelenburg sign hips experienced improvement of abductor muscle strength. An 18% (9% to 36%) increase could be found in functional hip scores. Mean increase in articulo-trochanteric distance was 24 mm (10 mm to 34 mm). Five patients older than 30 years at the time of osteotomy and two younger patients with prior hip incongruency had disappointing results and required arthroplasty. In all, 12 complications occurred in 128 osteotomies, in which complications were reported. Conclusions. This first systematic review of double and triple femoral neck lengthening osteotomies shows that favorable outcomes and few complications can be expected in coxa brevis, however, excessive caution is required in older patients with incongruent hips

Surgical treatment options for Femoroacetabular impingement (FAI) includes both surgical dislocation and hip arthroscopy techniques. The primary aim of this study was to evaluate and compare the survivorship of arthroscopies (scope) and surgical dislocations (SD) at minimum 5-year follow-up. The secondary aim was to describe differences in functional outcomes between the 2 groups. This was a retrospective, single surgeon, consecutive, case-series from a large tertiary care centre. We evaluated all surgeries that were performed between 2005 and 2011. Our institutional database was queried for any patient undergoing surgery for FAI (pincer (n=23), cam (n=306), or mixed (n=103) types). Patients with childhood pathologies i.e. Legg Calve Perthes and slipped capital femoral epiphysis were excluded. This resulted in 221 hips (169 males, 52 females) who underwent either SD (94, 42.5%) or scope (127, 57.5%). A manual chart review was completed to identify patients who sustained a complication, underwent revision surgery or progressed to a total hip arthroplasty (THA). In addition, we reviewed prospectively collected patient reported outcome measure (PROMs) using (SF12, HOOS, and UCLA). Survivorship outcome was described for the whole cohort and compared between the 2 surgical groups. PROMs between groups were compared using The Mann-Whitney U test and the survival between groups was assessed using the Kaplan-Meier Analysis and the Log-Rank Mantel Cox test. All analyses were performed in SPSS (IBM, v. 26.0). The cohort included 110 SDs and 320 arthroscopies. The mean age of the whole cohort was 34±10; patients in the SD group (32±9) were younger compared to the arthroscopy group (39±10) (p<0.0001). There were 16 post-operative complications (similar between groups) and 77 re-operations (more common in the SD group (n=49) due to symptomatic metal work (n=34)). The overall 10-year survival was 91±3%. Survivorship was superior in the arthroscopy group at both 5- (96% (95%CI: 93 – 100)) and 8- years 94% (95%CI: 90 – 99%) compared to the SD Group (5-yr: 90% (95%CI: 83 – 98); 8-yr: 84% (95%CI:75 – 93)) (p=0.003) (Figure 1). On average HOOS improved from 54±19 to 68±22 and WOMAC from 65±22 to 75±22. The improvement in PROMs were similar between the 2 groups. We report very good long-term joint preservation for the treatment of FAI, which is similar to those reported in hip dysplasia. In addition, we report satisfactory improvement in function following such treatment. The differences reported in joint survival likely reflect selection biases from the treating surgeon; more complex cases and those associated with more complex anatomy were more likely to have been offered a SD in order to address the pathology with greater ease and hence the inferior joint preservation identified in this group. For any figures or tables, please contact the authors directly

Despite recent advances in the management of slipped capital femoral epiphysis (SCFE), controversy remains about the treatment of choice for unstable slips. Surgical dislocation and open reduction has the advantage of identifying and preserving the blood supply of femoral head thereby potentially reducing the risk of avascular necrosis, (AVN). There is large variation in the literature from several small series about reported AVN rates ranging from two to 66% for unstable SCFE treated with surgical dislocation. The aim of our study was to analyze our experience with acute open reduction and internal fixation of unstable acute and unstable acute on chronic slips using the technique of surgical dislocation described by Professor Reinhold Ganz. A retrospective review of 11 patients (12 hips) treated by surgical dislocation, reduction and pinning as the primary procedure for unstable acute and unstable acute on chronic SCFE in a tertiary referral children's hospital was undertaken. This represents the entire series treated in this manner from September 2007 to January 2018. These procedures were performed by a team of Orthopaedic surgeons with significant experience performing surgical dislocation of the hip including patients with chronic SCFE, Perthes' disease, impingement and acetabular fractures. Demographic data, intraoperative records, postoperative notes and radiographs including details of subsequent surgery were reviewed. There were seven boys and four girls with mean age of 13.4 years, range 11 to 15 years at the time of surgical dislocation. Out of 12 hips, two had acute unstable slip while the remaining 10 had acute on chronic unstable slip. Six patients had good or excellent results. The remaining six patients developed AVN of which three patients had total hip replacement at six months, 17 months and 18 months following primary procedure. Seven patients required more than one operation. Three patients lost their correction and required re fixation despite surgical dislocation, reduction and fixation being their primary procedure. This series demonstrates a high percentage of AVN (50%) in severe unstable SCFE treated with surgical dislocation despite careful attention to retinacular flap development and intra operative doppler studies. This is in direct contrast to our experience with subcapital reorientation with surgical dislocation in stable slips where excellent results were achieved with a low rate of AVN. Pre-operative imaging with MRI and perfusion studies may identify where ischemia has occurred and might influence operative treatment. Based on our results, we do not recommend routine use of surgical dislocation in unstable SCFE. This technique requires further scrutiny to define the operative indications in unstable SCFE

Introduction. In situ pinning for classic slipped capital femoral epiphysis(SLIP) is evolving to a more direct and anatomic realignment of proximal femoral epiphysis; but in no study the result of such a treatment in Valgus Slip, an uncommon type of slipped capital femoral epiphysis, has been reported. Material and methods. Three hips in three patients (one male, two female) with valgus SCFE were treated by sub-capital realignment (two hips) or femoral neck osteotomy (one hip) for anatomic realignment of proximal femoral epiphysis. Extended retinacular flap technique performed through surgical hip dislocation in all hips. They followed clinically by Merle d'Aubigne Scale and visual analog scale for pain and radiographically for AVN, recurrence of SLIP, chondrolysis and osteoarthritis. Result. The age of the patients was 10,11 and 18 years. In all hips the neck-shaft angle was increased.18 years old male had bilateral chronic valgus SLIP with severe retro tilt of the head over the neck and bilateral acetabular dysplasia.11 years old girl with an acute valgus SLIP also had bilateral acetabular dysplasia and in 10 years old girl only one hip presented with acute on chronic valgus SLIP. All had severe displacement. The mean preoperative epiphyseal shaft angle (ESA) of 107.5° (range 85–125°) was reduced to 60° (range 55–70°) postoperatively. mean Merle d'Aubigne Scale was 16 and radiographically complete union and good alignment achieved without any complication. Conclusion. Anatomical realignment of proximal femoral epiphysis in this small series of patient with valgus type SCFE had good to excellent results

The intra-epiphyseal growth of the proximal femur has been focus of studies because of the potential relationship with the development of slipped capital femoral epiphysis and cam deformity in femoroacetabular impingement. We aimed to evaluate the developmental pattern of the epiphyseal tubercle and extension in normal boys and girls from eight to fifteen years, without hip conditions. We performed three-dimensional (3D) analysis of pelvic computed tomographic scans of 80 subjects with suspect of appendicitis, consisting of five boys and five girls for each age, from eight to 15 years old. Images were segmented slice by slice at the level of the growth plate using biplanar orientation. The 3D-segmented epiphyses were used to measure the location and height of the tubercle, the height of the epiphyseal extension, and the epiphyseal diameter. We found that the epiphyseal tubercle was eccentrically located at the posterolateral quadrant of the physeal surface. The absolute height of the epiphyseal tubercle did not vary between ages (R. 2. =0.04; p=0.101). The epiphyseal diameter increased with age (R. 2. =0.74; p<0.001), making the tubercle height proportionally smaller with the epiphyseal growth (9% reduction in tubercle height normalised by the epiphyseal diameter). The normalised epiphyseal extension height significantly increased by 160% from 8 to 15 years of age. Our observation validates the hypothesis of the cupping mechanism provided by the peripheral growth of the epiphyseal extension, while the epiphyseal tubercle relatively decreases in size during the skeletal growth. Further research will be important to determine the role of these structures in the epiphyseal stability